Background <p>Intra-procedural re-rupture (IPRR) during endovascular treatment of ruptured intracranial aneurysms is a challenging potential complication. Evidence specific to re-rupture after subarachnoid hemorrhage (SAH) remains fragmented.</p> Objective <p>To systematically review the incidence, mechanisms, anatomical risk factors, and outcomes of intra-procedural re-rupture during endovascular treatment of previously ruptured intracranial aneurysms.</p> Methods <p>A PRISMA 2020–compliant systematic review was performed using PubMed and Scopus from inception through April 2025. Studies reporting intra-procedural re-rupture during endovascular treatment of ruptured saccular intracranial aneurysms were included. Data extracted included patient and aneurysm characteristics, procedural context, mechanisms of re-rupture, and clinical outcomes. Risk of bias was assessed using ROBINS-I and CARE tools.</p> Results <p>Eleven studies encompassing 2,990 ruptured aneurysms reported 109 intra-procedural re-rupture events, yielding an incidence of 3.6%. Re-rupture occurred most frequently at the anterior communicating artery (34.9%). The predominant mechanisms were first- or framing-coil perforation (48.6%) and microcatheter or guidewire injury (18.3%). Overall mortality was 11.9%, and 59.6% of patients achieved favorable functional outcomes with successful hemostasis. Two illustrative cases from our institution demonstrate intra-procedural re-rupture following SAH, successfully managed with immediate balloon-assisted flow control.</p> Conclusions <p>Intra-procedural re-rupture during the treatment of ruptured intracranial aneurysms is a high-risk procedural complication. Although infrequent, it is a critical determinant of outcome. Recognition of high-risk aneurysm features and procedural triggers, coupled with preparedness strategies such as pre-positioned balloon control, is essential to mitigate morbidity and mortality.</p>